U-TEC Construction | Job Application Form

Date of Birth:

Format: mm/dd/yyyy

Are you legally permitted to work in the U.S.?

Yes

Have you worked for U-TEC before?

Yes

If Yes, when?

Did someone refer you to U-TEC?

Yes

If Yes, whom?

Do you have a valid Driver's License?

Yes

License Type:

CDL

Non-CDL

Duct Bank:

Overhead:

Outdoor Lighting:

Backhoe:

Trencher:

Directional Drill:

Bucket Truck:

Digger Truck:

Earth Auger:

Other Experience:
(Please specify)

Position / Job Title:

Foreman

Operator

Labor

Lineman

Other

Position / Job Title:

MOTOR VEHICLE DRIVER'S CERTIFICATION OF VIOLATIONS/ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

Name of Driver:

Last 4 of Social Security Number:

Date of Birth: Format: mm/dd/yyyy

Home Terminal (City & State):

Driver's License Number:

Expiration Date: Format: mm/dd/yyyy

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

I have had no Traffic Violations in the past 12 months

Date (mm/dd/yyyy):

Offense:

Location:

Type of vehicle operated:

Date:

Offense:

Location:

Type of vehicle operated:

Date:

Offense:

Location:

Type of vehicle operated:

Date:

Offense:

Location:

Type of vehicle operated:

Date:

Offense:

Location:

Type of vehicle operated:

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Date of Certification:

(Today's date) Format: mm/dd/yyyy

By checking this box, I confirm that the information provided above is accurate, I understand that knowingly providing false or misleading information may be considered grounds for employer action (up to and including dismissal), and I give my permission for U-Tec to verify my driving record with the DMV.

MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one):

Meets minimum requirements for safe driving.

Is disqualified to drive a motor vehicle pursuant to Section 391.15

Does not adequately meet satisfactory safe driving performance.

Action taken with driver:

Reviewed by:

(Signature) Cindy Griffin, Vice President

Date:

(Today's date) Format: mm/dd/yyyy